FUNDAMENTALS of

NURSING: special lecture on

Perioperative Nursing

Prepared by: Ronivin Garcia Pagtakhan, RN, MAN (c)

Perioperative Nursing

– a clinical specialty, refers to the role of the

nurse during the preoperative (before

surgery), intraoperative (during surgery)

and post operative (after surgery) phases

of the client’s surgical experience

What are the different types of

surgery?

- Severity/ Risk

- Urgency

- Reason

RISK

major surgery These are surgeries of the head, neck, chest, and

abdomen.

The recovery time can be lengthy and may involve a stay in intensive care or several days in the hospital.

There is a higher risk of complications after such surgeries.

Types of major surgery may include: removal of brain tumors

correction of bone malformations of the skull and face

repair of congenital heart disease, transplantation of organs, and repair of intestinal malformations

correction of spinal abnormalities and treatment of injuries sustained from major blunt trauma

correction of problems in fetal development of the lungs, intestines, diaphragm, or anus.

minor surgery

The recovery time is short and patient return to their usual activities rapidly.

These surgeries are most often done as an outpatient

Complications from these types of surgeries are rare.

Examples of the most common types of minor surgeries may include, but are not limited to, the following: placement of ear tubes

hernia repairs

correction of bone fractures

removal of skin lesions

biopsy of growths

URGENCY

ACCORDING TO DEGREE OF

URGENCY

Emergent – life-threatening – without

delay

Severe bleeding

Urgent – prompt attention – 24-30 hrs

Cholecystitis

Required – needs – weeks-months

Cataract

Elective – should be, not catastrophic

Scar repair

Optional – personal reference

cosmetic

Biopsy is the removal of a piece of tissue from an organ or other part of the body for microscopic examination to confirm or establish a diagnosis, estimate prognosis, or follow the course of a disease.

Curative surgery is the removal of the entire tumor. Even after curative surgery, you may still be given chemotherapy or radiation to kill micro-metastases. Micro-metastases are cancer cells that may still be in the body but cannot be detected by current technology.

Cryosurgery involves the use of liquid nitrogen or a very cold probe to freeze cancer cells.

Debulking surgery is when the entire cancer cannot be removed without serious damage to the body so the surgeon takes out only that portion of the tumor that can be removed safely. The rest of the tumor may be killed with radiation therapy or chemotherapy.

Electrosurgery uses an electrical current to destroy cancer cells.

Laser surgery is surgery in which a beam of light is used instead of a scalpel.

Mohs surgery is the removal of skin cancer by shaving off one layer at a time. The dermatologist (skin doctor) looks at each layer under a microscope. When the layers look normal (no cancer) the surgeon stops removing skin.

Reason

Prophylactic surgery

to prevent cancer when there is a good chance that a particular body tissue will become cancerous in the future.

Palliative surgery

does not treat the underlying disease but is done to control symptoms of cancer, such as pain.

Restorative or reconstructive surgery

commonly called plastic surgery

restores the function and appearance of an area after a previous surgery.

Staging surgery

determine the extent of the cancer, or how large it is and how much it has spread throughout the body. This is very important, as it will determine the course of treatment.

Ablative

Removal of a diseased organ

Surgery is affected by:

age

general health

nutrition

medications

mental status

Perioperative Nursing

3 PHASES OF

PERIOPERATIVE PERIOD

PREOPERATIVE PERIOD

begins with the decision to have surgery

and ends when the client is on the

operating table

Previous Medication History

Adrenal corticosteroids – do not d/c

abruptly CV collapse

Diuretics – thiazide diuretics resp

depression

Phenothiazine hypotension

Antidepressants: MAO hypotension

Tranquilizers anxiety, tension,

seizures of withdrawn suddenly

Insulin

Antibiotics – ―mycin‖ + curariform muscle

relaxant apnea

PHYSICAL PREPARATION - Preoperative

checklist

Nutrition and hydration

Consumption of clear liquids up to 2 hours

before elective surgery requiring general

anesthesia.

Fasting for 4 hours prior to surgery after

ingesting milk products

Eating a light breakfast 6 hours before the

procedure

A heavier meal 8 hours before surgery

Fasting for 8 hours prior to surgery after eating

fatty foods

Elimination Catheter insertion, Enema

Rest and Sleep

Hygiene Bath ,Remove cosmetics, Remove all hairpins and

clips, OR gown

Medication Discontinued, Preop meds

Personal valuables and prosthesis

Care of belongings, Remove all body prostheses

Special orders

NGT, insulin, etc

Special skin preparation

PREOPERATIVE TEACHING

proper timing

PAIN MANAGEMENT

PHYSICAL ACTIVITIES

DBE , Coughing exercises , Leg exercises,

Turning in bed

EMOTIONAL SUPPORT

PREOP CHECKLIST

CONSENT

HEALTH TEACHING (SPEC. POST OP

PROCEDURES)

LAB TESTS,ECG,X-RAY

SKIN PREP

BOWEL PREP

IV’S

NPO

PREOP MEDS,SEDATION AND ANTIBIOTICS

REMOVAL OF DENTURES,NAILPOLISH AND

JEWELRY

NUTRITION-TPN OR ENTERAL FEEDINGS PREOP

INFORMED CONSENT

protects the patient from unsanctioned

surgery and protects the surgeon from

claims of an unauthorized operation

nurse may ask patient to sign the form

and witness the patient’s signature

the physician provides appropriate

information:

flow of surgery

alternatives

possible risks, complications, disfigurement

what to expect early and late post op

Indications of Informed Consent

invasive procedure/ surgery

use of anesthesia

nonsurgical by there might be slight risk

involves radiation

Criteria of Informed Consent

Consent voluntarily given (without

coercion)

Competent subject

Surgery

Common surgical procedures

Appendectomy

An appendectomy is the surgical removal of the appendix, a small tube that branches off the large intestine, to treat acute appendicitis. Appendicitis is the acute inflammation of this tube due to infection.

Breast biopsy

A biopsy is a diagnostic test involving

the removal of tissue or cells for

examination under a microscope. This

procedure is also used to remove

abnormal breast tissue. A biopsy may

be performed using a hollow needle to

extract tissue (needle aspiration), or a

lump may be partially or completely

removed (lumpectomy) for examination

and/or treatment.

carotid endarterectomy

Carotid endarterectomy is a surgical procedure to remove blockage from carotid arteries, the arteries located in the neck that supply blood to the brain. Left untreated, a blocked carotid artery can lead to a stroke.

cataract surgery

Cataracts cloud the normally clear lens

of the eyes. Cataract surgery involves the removal of the cloudy contents with ultrasound waves. In some cases, the entire lens is removed.

cesarean section Cesarean section (also called a c-section) is the surgical delivery of a baby by an incision through the mother's abdomen and uterus. This procedure is performed when physicians determine it a safer alternative than a vaginal delivery for the mother, baby, or both.

cholecystectomy

A cholecystectomy is surgery to remove

the gallbladder (a pear-shaped sac near

the right lobe of the liver that holds bile).

A gallbladder may need to be removed

if the organ is prone to troublesome

gallstones, if it is infected, or becomes

cancerous.

coronary artery bypass surgery Most commonly referred to as simply "bypass surgery," this surgery is often performed in people who have angina (chest pain) and coronary artery disease (where plaque has built up in the arteries). Bypass surgery consists of grafting veins or arteries from the aorta (a major artery that carries blood from the heart to the rest of the body) to the coronary artery, bypassing areas that are blocked. Veins are usually taken from the leg.

Craniotomy/craniectomy

debridement of wound, burn, or infection Debridement involves the surgical removal of foreign material and/or dead, damaged, or infected tissue from a wound or burn. By removing the diseased or dead tissue, healthy tissue is exposed to allow for more effective healing.

dilation and curettage (Also called D

& C.)

A D&C is a minor operation in which the

cervix is dilated (expanded) so that the

cervical canal and uterine lining can be

scraped with a curette (spoon-shaped

instrument).

free skin graft A skin graft involves detching healthy skin from one part of the body to repair areas of lost or damaged skin in another part of the body. Skin grafts are often performed as a result of burns, injury, or surgical removal of diseased skin. They are most often performed when the area is too large to be repaired by stitching or natural healing.

hemorrhoidectomy A hemorrhoidectomy is the surgical removal of hemorrhoids, distended veins in the lower rectum or anus.

hysterectomy A hysterectomy is the surgical removal of a woman's uterus. This may be performed either through an abdominal incision or vaginally.

hysteroscopy Hysteroscopy is a surgical procedure used to help diagnose and treat many uterine disorders. The hysteroscope (a viewing instrument inserted through the vagina for a visual examination of the canal of the cervix and the interior of the uterus) can transmit an image of the uterine canal and cavity to a television screen.

mastectomy A mastectomy is the removal of all or part of the breast. Mastectomies are usually performed to treat breast cancer.

There are several types of mastectomies, including the following:

partial (segmental) mastectomy, involves the removal of the breast cancer and a larger portion of the normal breast tissue around the breast cancer.

total (or simple) mastectomy, in which the surgeon removes the entire breast, including the nipple, the areola (the colored, circular area around the nipple), and most of the overlying skin, and may also remove some of the lymph nodes under the arm, also called the axillary lymph glands.

modified radical mastectomy, in

which the surgeon removes the entire

breast (including the nipple, the areola,

and the overlying skin), some of the

lymph nodes under the arm, and the

lining over the chest muscles. In some

cases, part of the chest wall muscles is

also removed.

radical mastectomy, involves removal of the entire breast (including the nipple, the areola, and the overlying skin), the lymph nodes under the arm, and the chest muscles.

partial colectomy A partial colectomy is the removal of part of the large intestine (colon) which may be performed to treat cancer of the colon or long-term ulcerative colitis.

prostatectomy The surgical removal of all or part of the prostate gland, the sex gland in men that surrounds the neck of the bladder and urethra - the tube that carries urine away from the bladder. This may be performed for an enlarged prostate, benign prostatic hyperplasia (BPH), or if cancerous.

Penectomy

Removal of a diseased penis

tonsillectomy The surgical removal of one or both tonsils. Tonsils are located at the back of the mouth and help fight infections.

INTRAOPERATIVE PHASE

begins with the admission of the client

to the surgical area and ends when the

client is transferred to the recovery

area.

MAINTAIN SURGICAL ASEPSIS, MONITOR CLIENT

STATUS,, APPROPRIATE GROUNDING DEVICES,

FLUID BALANCE AND SPONGE/INSTRUMENT

COUNT

SCRUB NURSE – HANDLES EQUIPMENT ,

MATERIALS TO THE SURGEON, SPONGE

AND INSTRUMENT COUNT

( STERILE)

CIRCULATING NURSE- ENSURES ADEQUACY

OF SUPPLIES, SKIN PREP ,

DOCUMENTATION , HANDLES STERILE

EQUIPMENTS BY FORCEPS

INTRA-OPERATIVE CARE

The OPERATING ROOM

free from contaminating particles, dusts,

pollutants, radiation, noise

ZONES

Unrestricted – street clothes are allowed

Semi-restricted – scrubs, shoe covers,

cap and mask

Restricted zone

SURGICAL SKIN PREPARATION

Cleaning, shaving, applying antimicrobials

POSITIONING

Performed after anesthesia is given

Provide correct position for the specific

procedure

Protect bony prominences

Avoid strain or injury to muscles, bones

and joints

Protect the skin – lift rather than pull or roll

the client into position

SPECIFIC THERAPEUTIC

POSITION HIGH FOWLERS-60-90’

FOWLER-45-60’

SEMI-FOWLERS-30-45’

LOW-FOWLERS-15-30’

SUPINE

DORSAL RECUMBENT

LITHOTOMY

SIMS LATERAL

PRONE

KNEE-CHEST

SIDE-LATERAL

ORTHOPNEIC

TRENDELENBURG

MODIFIED TRENDELENBURG

OTHER RESPONSIBILITIES

Draping

Assist in preparing and maintaining the sterile

field

Open sterile packages during surgery

Provide meds and solutions for the sterile field

Monitor and maintain sterile environment

Manage catheters, tubes, drains and

specimens

Perform sponge, instrument and sharp counts

Document care provided and client responses

Transferring of client to RR

Endorsement

THE SURGICAL EXPERIENCE ANESTHESIA

state of narcosis (severe CNS depression)

Analgesia, relaxation, reflex loss

General Anesthesia – inhaled, most

common

Volatile liquid agents – vapors

Halothane, enflurane, isoflurane, sevoflurane

Gas anesthetics – with oxygen, N2O

IV ANESTHESIA

Barbiturates, benzodiazepines, non-barbiturates

Opioids

used for induction (initiation) or mainstream

used to produce conscious sedation

Advantages

onset is pleasant

non-explosive

easy to administer

decreased nausea

and vomiting

Contraindications

children

powerful

respiratory

depressant

CONSCIOUS SEDATION

depression of LOC without impairment of

the patient’s ability to maintain a patent

airway and to respond to physical

stimulation and verbal command

Medazolam (Versed), Diazepam

first dose is given by the physician

succeeding doses – RN, Nurse-anesthetist

WOF: dysrhythmias, CNS, Respi

depression

O2, resuscitation, pulse oximetry, cont.

ECG, VS

Adjunctive Agents : Neuromuscular

blockers – purified curare

REGIONAL ANESTHESIA

form of local anesthesia

anesthetic agent is injected around nerves

so that the area supplied is anesthetized

SPINAL ANESTHESIA

extensive conduction nerve block

local anesthetic agent into subarachnoid

space at the lumbar level (L4, L5)

lower extremities, perineum, lower

abdomen

knee-chest position, place supine after

injection

if high level block, head and shoulders are

lowered

anesthesia and paralysis of toes, perineum

then legs and abdomen

may also reach upper thoracic and cervical

spine resp paralysis

CONDUCTION BLOCKS

Epidural anesthesia

injection of local anesthetic into the spinal

canal in the space around the dura mater

higher dose than spinal

no headache

disadvantage: epidural space vs.

subarachnoid space

Brachial plexus

arm

Paravertebral anesthesia

chest, abdominal wall, extremities

Transsacral (caudal)

perineum, lower abdomen

Local Infiltration Anesthesia

Advantages – simple, economical,

nonexplosive, minimal equipment, postop

recovery is shortened, no GA side effects,

short superficial surgical procedures

TAKE NOTE: Anesthesia

Halothane-respiratory and cardiovascular depression-monitor VS, open IV site-ABC’s prevent aspiration

Nitrous Oxide- Hypotension and nausea and vomiting- adequate O2

IV thiopental Na- decreased BP , respiratory depression, laryngospasm- ABC

spinal and saddle – hypotension and HA- increased OFI

conduction block/epidural block- hypotension and respiratory depression-HA not experienced

local – excitability and hypersensitivity;no epinephrine on fingers

STAGES OF ANESTHESIA

STAGE 1. BEGINNING ANESTHESIA,

analgesia, sedation and relaxation

warmth, dizziness, feeling of

detachment

ringing, roaring, buzzing in ears

aware of being unable to move the

extremities noises are exaggerated

STAGE 2. EXCITEMENT, DELIRIUM

struggling, shouting, talking, singing,

laughing, crying – decreased if

anesthesia is given quickly and

smoothly

pupil dilates but constricts if with light

PR rapid, RR irregular

Vomiting

Restraining

STAGE 3. SURGICAL ANESTHESIA,

OPERATIVE ANESTHESIA

unconscious

pupils – small but reactive

RR irregular, PR normal

Skin – pink, flushed

No hearing

STAGE 4. MEDULLARY

DEPRESSION, DANGER

if anesthesia is too much

RR shallow

Pulse weak, thready

Pupils – widely dilated, non reactive

Cyanosis death

SPINAL SET

NITROUS OXIDE TANK

OR gowns and surgical

equipment

Sutures:

http://en.wikipedia.org/wiki/File:HechtnaaldenG.jpg

Suture

medical device use to hold skin, internal

organs, blood vessels and all other

tissues of the human body together

after they have been severed by injury,

incision or surgery.

Assessment of the suture line:

Stitched too tight or too loose

Too many or too few stitches

Suture holes not equidistant for the edges so

that the bite is not uneven, or uneven spacing

between sutures

Inversion or eversion of tissue edges

Edges of tissue overlapping and heaped on

each other.

Types of stitch:

Simple interrupted suture

Inserted singly through each side of the

wound and tied with a surgeon’s knot. Several

of these may be used at short intervals ( 4—

8mm apart) to close large wounds and share

tension. Easy to keep clean, can be replaced

singly and will evert edges of the flap.

Horizontal mattress suture

Evert the mucosal or skin margins,

thereby bringing greater areas of raw

tissue into contact. Useful for closing

wounds over bony deficiencies such as

oro-antral fistulae or cyst cavities.

Vertical mattress suture

Specially designed for use in the skin.

Pass through at two levels:

(i) Deep—provides

support and adduction of wound surface

(ii) Superficial—draw

edges together and evert them

Vertical Mattress is a suture technique

most commonly used in anatomic

locations which tend to invert, such as

the posterior aspect of the neck or the

palm of the hand.

This type of suture is good for deep

lacerations, instead of combining two

layers of deep and superficial sutures.

Continuous suture

Disadvantaged that if they cut out at

one point the whole suture will slacken.

Advantage—only two knots present.

¨ Simple continuous— applies pull on

the wound obliquely

¨ Continuous blanket stitch—more firm

and stable. Gives traction on the wound

edges at right angles to the wound

¨ Purse string suture—useful as a deep

suture for wounds of the skin of the

face.

Suture sizes:

defined by the United States

Pharmacopeia (U.S.P.).

Sutures were originally manufactured

ranging in size from #1 to #6, with #1

being the smallest.

Modern sutures range from #5 (heavy

braided suture for orthopedics) to #11-0

(fine monofilament suture for

ophthalmics).

Types of Suture Material

Plain catgut

Absorbable biological suture material.

taken from bovine intestines.

absorbed by enzymatic degradation.

Chromic

Absorbable biological suture material.

taken from bovine intestines.

offers roughly twice the stitch-holding time of

plain catgut.

absorbed by enzymatic degradation.

Note – catgut is no longer used in the UK for

human surgery.

Polyglycolic acid (P.G.A.)

Synthetic absorbable suture material.

thread extremely smooth, soft and knot safe.

Polydioxanone (PDS)

Synthetic absorbable suture material.

Indication

Plain catgut Chromic Polyglycolic

acid (P.G.A.)

Polydioxanone

(PDS)

-all surgical

procedures

- for tissues

regenerating

faster are

involved.

- General

closure,

ophthalmic,

orthopedics,

obstetrics/gyne

, GI

-all surgical

procedures

- for

tissues that

regenerate

faster.

Subcutaneou

s,

intracutaneo

us closures,

abdominal

and thoracic

surgeries

- combination of

an absorbable

suture

- extended

wound support

is desirable,

pediatric

cardiovascular

surgery,

ophthalmic

surgery

Removal of Sutures

facial wounds 3–5 days

scalp wound 7–10 days

trunk of the body 7–10 days.

limbs 10–14 days

joints 14 days

Others…. Tissue adhesives

topical cyanoacrylate adhesives ("liquid

stitches"), combination or alternative to, sutures

in wound closure.

adhesive is liquid exposed to water/water-

containing substances/tissue cures

(polymerizes) forms a flexible film that bonds

to the underlying surface.

act as a barrier to microbial penetration as long

as the adhesive film remains intact.

Contraindications: near eyes and a mild

learning curve on correct usage.

Antimicrobial sutures

sutures coated with antimicrobial

substances to reduce the chances of wound

infection.

INTRAOP COMPLICATIONS

Nausea and Vomiting

Hypoxia, respiratory complications

Hypothermia (below 36.6)

d/t room temperature, cold fluids, cold

gases, open body, wound, cavities, dec.

muscle activity, age, drugs

Check: core temp, u/o, ECG, BP, ABC,

electrolytes

Malignant Hyperthermia

d/t anesthetic agents, muscle relaxants,

syphatomimetics, theo/aminophylline,

anticholinergic, cardiac glycosides

Risks: bulky, strong muscles, muscle cramps,

weakness

CM: tachycardia, SNS stimulation

(vent.dysrhythmias, hypotension, dec CO, oliguria,

cardiac arrest, tetany-like movements, increased

temperature 1 degree every 15 minutes

Mgt: critical assessment 10-20 mins post induction

or 24 hrs postop; stop anesthesia, surgery; 100%

oxygen; DANTROLENE Na – muscle relaxant,

NaHCO3

POSTOPERATIVE PHASE

begins with the admission of the client

to the PACU and ends when healing is

complete

PHASE I – Immediate postoperative care,

intensive nursing care

PHASE II – Ongoing postoperative care

Step down, Sit up or Progressive Care Unit

– 4-6 hours

NURSING RESPONSIBILITIES

ASSESSMENT

Respiratory Status

Airway patency, O2 sat, Effectiveness of ventilation

Cardiovascular Status

BP, All pulses, Color, skin temp, edema , Urine

output

CNS

LOC, Orientation, Reflexes, Ability to move

extremities

Fluid Status

IVF, Urine output, Wound drainage, Drainage from

catheters, tubes and drains, Skin turgor, edema, VS

Status of wound

Dressing and drainage

Pain

Nausea and Vomiting

Keep all lines patent

Assure that monitors and equipments are

functioning

Positioning

Help arouse and orient the client

Facilitate oxygenation

Treat hypotension

Provide for safety AND comfort

Readiness for Discharge from PACU

uncompromised pulmonary function

pulse oximetry ok

stable VS

oriented

U/O > 30cc/hr

N/V under control

Minimal pain

SURGICAL WARD

postop bed

1st hours

Assess and manage ventilation

Hypoventilation

Atelectasis

Pneumonia

PE : IPPA

Breathing, coughing (except intracranial

surgery. IOP, plastic surgery)

CPT

Incentive spirometry

Assess and Manage Hemodynamic

stability

Shock and hemorrhage

WOF dec BP 90 mmHg, dec, 5 mmHg q

15mins

IVF

FVE

I&O

Venous stasis – d/t dehydration,

immobility, pressure on legs DVT

(Homan’s sign, pain swelling on calf, fever,

chills, diaphoresis) = leg exercises,

antiembolism stocking, early ambulation,

low dose heparin

Assess and Manage the Surgical Site

WOF bleeding, dressing, drains

Hematoma

Infection after 5 days, wound dehiscence

and evisceration

Assess and Manage Pain

Maintain body temperature

Assess Mental status and NVS

LOC, speech, orientation

Assess GI function

N/V, hiccups, NGT, Antiemetics,

phenothiazine

Liquid - clear liquid soft solid food

Assess and manage voluntary voiding

Urinary retention

Void within 8 hours post surgery non

catheter interventions catheter

Encourage Activity

Early ambulation

Bed exercises

Maintain safe environment

Provide emotional support to the patient

and family

POST-OPERATIVE COMPLICATIONS

SHOCK

PARALYTIC ILEUS

ATELECTASIS AND PNEUMONIA - 2ND DAY

EMBOLISM- 2ND DAY

WOUND INFECTION-3-5D

DEHISCENCE AND EVISCERATION-5-6D

PSYCHOSIS

CARDIOVASCULAR COMPROMISE

URINARY RETENTION-8-12H

URINARY INFECTION -5-8 D

DVT-6-14 DAYS-1 YEAR

POST-OPERATIVE CARE

POST OP- MONITOR VS

Q15X4;Q30X2;Q1HX2 THEN PRN

MONITOR I AND O , K LEVEL , CVP, BOWEL SOUNDS, BREATH SOUNDS AND LOC

RESPIRATORY PHYSIOTHERAPY,TCBD

INCENTIVE SPIROMETRY-20 SECS INHALATION

ENCOURAGE AMBULATION

REFER IF UNABLE TO VOID IN 8 HOURS

APPLY TED HOSE AND PNEUMATIC COMPRESSION DEVICE,CHECK FOR HOMAN’S SIGN

Wound Care

DRESSINGS

PROTECT FROM INJURY , BACTERIAL CONTAMINATION

PROVIDE HUMIDITY

INSULATION

ABSORB DRAINAGE

DEBRIDE THE WOUND

PREVENT HEMORRHAGE

SPLINT / IMMOBILIZE

COMFORT

GUAZE, SYNTHETIC , SECURING, TEGADERM

TYPES OF DRESSINGS

DRY TO DRY – TRAP NECROTIC DEBRIS AND EXUDATE

WET TO DRY ( SALINE AND ANTI MICROBIAL SOLUTION – SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE

WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED( VARIATION @ DRYING)

WET TO WET – KEEP MOIST – WOUND BATHED – MOISTURE DILUTES VISCIOUS EXUDATE

pressure ulcer dressings

dry gauze stage II-IV

tegaderm film/ hydrocolloid – SI - SII

Absorptive Dressing III

Hydrogel – II - III

SURGICAL DRAINS

PENROSE – OPEN ENDS

CLOSED WOUND DRAINAGE ( SUCTION) –

DECREASE ENTRY OF MICROBES-

HEMOVAC / JACK PRATT TO RESERVOIR

D/C 3-7 DAYS POST – OP

penrose

hemovac

Jackson prat

Thank you very much!

God Bless!